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SEXUALLY ORIENTED BUSINESS MANAGER REGISTRATION Fee…..$75.00 Note: If the licensee is the only manager, there is no requirement to file a separate Manager Registration form or pay a separate fee of $75.00 This form must be completed for all Sexually Oriented Businesses for each manager. All applicants will be fingerprinted in order to conduct a background investigation. Name of Licensee: Trade Name of Establishment: Address of Business: Name of Manager: Date of Birth: Address: Home Phone: Business OATH OF APPLICANT I declare under penalty of perjury in the second degree that I have read the foregoing registration and that all information contained herein is true, correct and complete to the best of my knowledge. Signature of Applicant Date ---PAGE BREAK--- APPLICATION FOR SEXUALLY ORIENTED BUSINESS LICENSE CITY & COUNTY OF BROOMFIELD NEW LICENSE $950.00 REGISTRATION OF MANAGER $ 75.00 RENEWAL OF LICENSE $950.00 1. Name of Applicant: Telephone No.: 2. Mailing Address: 3. Trade Name: 4. Business Address: 5. Name of Manager: Telephone No.: Home Address: Date of Birth: 6. If Applicant is an Individual: Name: Telephone No.: Address: Date of Birth: 7. If Applicant is a Corporation, list all Officers and Directors: (attach a separate sheet if necessary) Name Address Date of Birth 8. If the Applicant is a limited liability company, list all members responsible for the management of the company: (attach a separate sheet if necessary) Name Address Date of Birth 9. Has the Applicant or any Officer, Director or Member of the Applicant ever been convicted of any sex offense or crime connected with another sexually-oriented business, including for example, distribution of obscenity, prostitution, pandering or tax violation? Type of Offense Date of Offense City, County and State of Conviction Date of Conviction or Date of Release from Confinement 10. On the premises for which this application is made, do you have the following? Adult Arcade Adult Bookstore/Adult Video Store_____ Adult Cabaret_____ Adult Motel_____ Adult Theater_____ Adult Motion Picture Theater_____ ---PAGE BREAK--- 11. Approved Fire Inspection, Building Inspection and Police Background reports MUST accompany this application. 12. A diagram must accompany this application which details the following: Configuration of the premises (to scale, with accuracy of plus or minus six inches) Total floor space Designated use of area Designation of rooms where patrons are not permitted NO CHANGES CAN BE MADE WITHOUT CITY COUNCIL APPROVAL. 13. Attach a vicinity map showing approved sexually-oriented businesses, churches, schools, public parks and open space, residentially zoned property, and day care facilities within 1,500 feet of the site. STATE OF COLORADO ) ) ss. COUNTY OF BROOMFIELD ) The affiant, being first duly sworn upon oath, deposes and says: if the applicant is an individual, that the affiant is the applicant above named, or that the affiant is filing this application on behalf of the partnership, limited partnership, corporation or limited liability company; that the affiant has read the foregoing application, the application is true and correct of affiant’s own knowledge and affiant agrees to conform to all requirements set forth in Chapter 5-36 of the Broomfield Municipal Code, as amended. Individuals, Partnerships, Limited Partnerships, Officers of the Corporation and members of Limited Liability Companies must sign here. Subscribed and sworn before me this of Notary Public My Commission (Seal) ---PAGE BREAK--- SEXUALLY ORIENTED BUSINESS EMPLOYEE REGISTRATION All employees MUST be registered within five days of employment, pursuant to Section 5-36-070 of the Broomfield Municipal Code, as amended. NAME OTHER NAMES USED ADDRESS PHONE BIRTH DATE